Musculoskeletal Injections

Current Royal College of Rheumatology position statement

There is a concern that steroids can increase risk from the novel coronavirus (Covid-19).

Steroids have been associated with an increased risk of mortality in patients with influenza and delayed viral clearance in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection.

Although they were widely used in management of severe acute respiratory syndrome (SARS), there was no good evidence for benefit, and there was persuasive evidence of adverse short- and long-term harm.

Injected steroids have also been shown to cause a variable degree of adrenal suppression for at least some weeks.

The potential impact of this immunological suppression in a patient incubating COVID-19 at the time or in the future is unknown. Because of this, we should consider alternatives to steroids where possible. If steroids are needed, use the lowest possible dose for the shortest possible time.
  • Intra-articular injections for inflammation – only use for inflammatory joints where there is active synovitis +/- effusion, and consider using lowest clinically effective doses (maximum 40mg depomedrone/ triamcinolone for large joints; 20mg for smaller joints). For children and young people with Juvenile Idiopathic Arthritis, consider using triamcinolone acetonide rather than hexacetonide, particularly if multiple joints injected.

  • You will be able to request a home visit through NHS 111 who will triage your requests and make arrangements for a local GP to visit you if that is indicated.  Please be aware that the GP visiting you may not have access to your clinical record and medical history.

  • Recommend simple analgesia, activity modification, splinting where appropriate and exercise as first line and in the majority. Only consider if patient has high levels of pain and disability, that has failed first line measures, and continuation of those symptoms will have a significant negative effect on the their health and well-being. Must be supported with guidance related to activity modification and exercise therapy

In the light of this statement we have agreed that we are not prepared to do cortico-steroid injections in high risk groups. This includes:
  • All shielding patients
  • Those who are 70+
  • Those who are pregnant
  • Lung conditions that aren’t severe (such as asthma, COPD, emphysema or bronchitis)
  • Heart disease (such as heart failure)
  • Diabetes
  • Chronic kidney disease
  • Liver disease (such as hepatitis)
  • Conditions affecting the brain or nerves (such as Parkinson’s disease, motor neurone disease, multiple sclerosis or cerebral palsy)
  • Conditions that mean a high risk of getting infections
  • Taking medicine that can affect the immune system (such as low doses of steroids)
  • Those who are very obese (a BMI of 40 or above)

If you are not a shielding patient and do not fit into any of the above groups and have read the Royal College statement as outlined above and wish to proceed to an injection download and return our Covid Consent form.